Look Good...Feel Better (LGFB) workshops are designed to help women cope with the appearance side effects of cancer treatment. To help us serve you better, please complete this brief questionnaire. The information you provide will be used as we continually enhance the LGFB program.

1.

How did you hear about LGFB?

Medical professional (doctor, nurse, social worker)

Medical professional (doctor, nurse, social worker)

Friend or relative

Friend or relative

Media (magazine ad, television, radio

Media (magazine ad, television, radio

Local American Cancer Society office

Local American Cancer Society office

Web site (LGFB or other Web site)

Web site (LGFB or other Web site)

Hairdresser (or stylist)

Hairdresser (or stylist)

Another patient

Another patient

The LGFB toll-free number

The LGFB toll-free number

Other

2.

How satisfied were you with the LGFB program overall?

Very Satisfied

Very Satisfied

Satisfied

Satisfied

Neutral

Neutral

Unsatisfied

Unsatisfied

Very Unsatisfied

Very Unsatisfied

Comment:

500 characters left.

3.

How would you rate the value of this program in improving your self-image?

Very Useful

Very Useful

Useful

Useful

Of Little Use

Of Little Use

Not Useful

Not Useful

n/a

n/a

Comment:

500 characters left.

4.

Would you recommend LGFB to other cancer patients?

Yes

Yes

No

No

Comment:

500 characters left.

5.

How satisfied were you with the following?

Very Satisfied

Satisfied

Neither Satisfied nor Dissatisfied

Dissatisfied

Very Dissatisfied

N/A

Your ability to find and access the workshop

Ease of registration for the workshop

Organization of the workshop

Group format of the workshop

Knowledge of the beauty professional volunteers

Professionalism of the beauty professional volunteers

Complimentary makeup kit

LGFB patient instruction booklet

6.

Were the following subject areas covered during your workshop?

Yes

No

Skin Care

Makeup

Wigs

Head Coverings

Nail Care

Comment:

500 characters left.

7.

Please rate the usefulness of the information provided in the LGFB workshop regarding the following:

Very Useful

Useful

Of Little Use

Not Useful

N/A

Skin Care

Makeup

Wigs

Head Coverings

Nail Care

Comment:

500 characters left.

8.

What is your five-digit zip code?

50 characters left.

9.

In what state did you attend the LGFB workshop?

50 characters left.

10.

In what city did you attend the LGFB workshop?

50 characters left.

11.

At which type of facility was the program held?

Hospital

Hospital

Cancer Center

Cancer Center

American Cancer Society Office

American Cancer Society Office

Other

12.

On what date did you attend the LGFB workshop? Month:

January

January

February

February

March

March

April

April

May

May

June

June

July

July

August

August

September

September

October

October

November

November

December

December

13.

On which day of the month did you attend the LGFB workshop?

50 characters left.

14.

Please select your age range:

18 - 29

18 - 29

30 - 39

30 - 39

40 - 49

40 - 49

50 - 59

50 - 59

60 - 69

60 - 69

70 - 79

70 - 79

80 - 89

80 - 89

Prefer not to answer

Prefer not to answer

15.

What is your ethnic background?

African American/Black

African American/Black

American Indian/Alaskan Native

American Indian/Alaskan Native

Asian

Asian

Chicana or Mexican-American

Chicana or Mexican-American

Other Hispanic/Latina

Other Hispanic/Latina

Caucasian/White

Caucasian/White

Native Hawaiin or other Pacific Islander

Native Hawaiin or other Pacific Islander

Prefer not to answer

Prefer not to answer

16.

For what type of cancer are you being treated?

Brain & Other Nervous System

Brain & Other Nervous System

Breast

Breast

Colon & Rectum

Colon & Rectum

Hodgkin's Disease

Hodgkin's Disease

Leukemia

Leukemia

Lung

Lung

Lymphoma

Lymphoma

Melanoma of the Skin

Melanoma of the Skin

Multiple Myeloma

Multiple Myeloma

Ovarian

Ovarian

Pancreas

Pancreas

Uterine or Endometrial

Uterine or Endometrial

Other

17.

Have you participated in any other programs or services offered by the American Cancer Society?

Reach to Recovery

Reach to Recovery

I Can Cope

I Can Cope

tlc catalog

tlc catalog

Road to Recovery

Road to Recovery

Cancer Survivor's Network

Cancer Survivor's Network

Other

Thank you for taking the time to complete this evaluation. The information you provide will not be given or sold to any other organization. Look Good...Feel Better is offered through the collaborative efforts of the Personal Care Products Council Foundation, the American Cancer Society, and the Professional Beauty Association|National Cosmetology Association.

18.

(OPTIONAL) Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:

Last Name:

Email Address:

emailaddress@xyz.com

Address 1:

Address 2:

City:

State/Province(US/Canada):

Postal Code:

19.

Would you like to receive information regarding future LGFB activities?